Foreword from the Ombudsman
‘This must never happen again.’ That phrase is uttered every time an NHS scandal hits the papers. But as we saw in the similarities between inquiries into maternity services in East Kent and Morecambe Bay seven years earlier, lessons are not always learnt. It is as vital as ever that my Office continues to call for action to improve learning, accountability and, ultimately, safety.
The last ten years have seen significant activity from policymakers to improve patient safety.
We have the NHS Patient Safety Strategy and welcome the introduction of the Patient Safety Incident Response Framework, which recognises the complexity of systems and the risks to staff and patients of a blame culture.
And yet, it is clear from the analysis of our most serious patient safety cases through this report that there is a gaping hole between best practice policy and consistent real-life practice. We may have a very sophisticated understanding of how to prevent patient safety incidents and avoid compounding harm for patients, families and staff when things do go wrong. But our evidence suggests that, on the ground, this is regrettably not always implemented.
Sadly, but perhaps inevitably, mistakes will happen in a complex health system that relies on human judgement. But every time my Office rules that a patient died in avoidable circumstances, it means that incident was not adequately investigated or acknowledged by the Trust. It also means staff, patients and their families had to go through an unacceptably long and painful process to make sure action was taken to address shortcomings and justice was achieved for the patient.
In this report, we consider the reasons for the continued failures to accept mistakes and take accountability for turning learning into action and improvement. We pose questions on how to embed an honest, open and unafraid culture in our healthcare system that supports staff and patients to challenge and learn.
Complex systems need robust regulation and oversight to recognise good practice and identify poor systems. When regulation and oversight work well, they also serve to keep people safe from harm. We need to see less fragmentation of the patient safety landscape. This report will have failed if it prompts the creation of yet another patient safety body or initiative. What we need is a streamlined system that works together, with real leadership from Government.
But the biggest threat to patient safety is a system at breaking point. In this report, we recognise that the NHS itself can only go so far in improving patient safety. We need to see concerted and sustained action from Government to make sure NHS leaders have the tools to prioritise the safety of patients and are accountable for doing so. This means getting past politics to put patient safety at the very top of the agenda.